Cervix Pre-Cancer Current

Treatment Modalities
Dr. Hermawan, SpOG
(Oncologyst)
GynecoOncologyst
Department
Medical Faculty of Sebelas
Maret University
DR Moewardi General Hospital

Cervix Pre-Cancer lesion

Another Terminology : Cervix Displasia

Usually no complain
Common complain : Discharge, Post coital
bleeding
Diagnosis pap smear
Good Prognosis With Adequat Management.

CERVICAL CANCER

NATURAL HISTORY
Cronic HPV Infection

Pre - CANCER
15 %

NORMAL

CIN I

30 %

CIN II

40 %

Low grade SIL

CANCER
45 %

CIN III

STAGE 0

20 %

High grade SIL

IDENTIFIED by VIA METHODE

INVASIVE

Pap Smear Terminology

1943
1953

Papanicolaou

1967
1988

Neoplasia Intraepitel Serviks (Richart RM)

1990
1990

Modifikasi Neoplasia Intraepitel Serviks

1991
2001

The Bethesda System

Displasia - Karsinoma Insitu (Reagan)

The Bethesda System
British Society for Clinical Cytology
The Bethesda System

(Bethesda System)
Low grade squamous intraepithelial lesion (LSIL) :
- CIN I
- HPV Infection
High grade squamous intraepithelial lesion (HSIL)
- CIN II
- CIN III
- Ca In situ

Classification Differences
Class I

Class II

Normal

WNL

Mild

Inflam

Normal

NEGATIF

Mod

Dysplasia
CIN I

Atypia
Benign
Cellular
Changes

Class III

CIN II

Koilocytosis

Class IV
Sev
CIS

Class V
Cancer

CIN III

Cancer

AS
CUS

LGSIL

HGSIL

HGSIL

Carcinoma

AS
CUS

LGSIL

HGSIL

HGSIL

Carcinoma

Normal Cervix

Cervix Pre-Cancer lesion

Cervix Pre-Cancer lesion

Diagnosis
Visual Inspection of Acetat Acid (VIA)
Simplest Modalities
Done in remote area when no Pap-smear facility.
Pap-Smear :
For every woman that have sexual activity
At least performed twice every year or depend on
prior history
HPV Test (Hybrid Capture II)
Perfomed when Pap-Smear ASCUS
Colposcopy
Perfomed When we found every Abnormal
PapSmear lesion

Cervic Pre-Cancer lesion

Low grade SIL

Low grade SIL

Cervic Pre-Cancer lesion

High grade SIL

High Grade SIL

Convensional Pap Smear

Examination
Spesifisity 98%, sensitifity 51%
(based on 84 metaanalisis study
from The Agency for Health Care
Policy)
50% negative false caused by
inadequate sampling and
sample transfer.

Pap Smear

Colposcopy
Peformed in every
abnormal Pap Smear

Low grade SIL

High Grade SIL

Low grade SIL

Invasive Cancer

Biopsy

Performed in cervix mass / tumor.

Cervix Mass

Cervix Pre-Cancer lesion

Treatment Modality
Treatment in Pre-Cancer lesion give almost satisfied outcome so early
detection is important step.
LSIL (CIN I) :
1. Cryotherapy
2. Cauterization
3. LEEP

1.
2.
3.
4.
5.

HSIL (CIN II III) :

Cryotherapy
Cauterization
LEEP
Conization
Histerectomy

Cryotherapy

LEEP

Conization

Cryotherapy
Destroyed all patologyc tissue lesion with Frozen
methode.
NO 2 - 65 0C ~ - 85 0C
CO 2
Freezing
Thawing

intracellular
crystalization

cell
rupture

2 mm
5 mm

cervix

Recovery zone

- 20 0C
0 0C

Lethal zone
- 85 0C

probe

Ice Crystal thickness 7 mm

< - 200C

: lethal

0 ~ - 20 0C : recovery zone
- 20 ~ - 85 0C : lethal zone

Recovery zone

Cant destroyed
tissue more than 5
mm thickness

Cryotherapy equipment

Cryo gun

Probes
Liquid gas : CO2 or NO2
gel
Desinfectant
Vagina Speculum
Asetat Acid 3 5 %
Colposcope

10
1
2

5
4
6

9
8

1. Probe
2. Trigger
3. Handle grip
(fiberglass)
4. Yoke
5. Instrument inlet of
gas from cylinder
6. Tightening knob
7. Pressure gauge
showing cylinder
pressure
8. Silencer (outlet)
9. Gas-conveying tube
10. Probe tip

Patient Conditions
LGSIL
HGSIL (???)
Cervix with normal shape
SIL : Average lesion thickness : 1,24 mm,
HGSIL : deppest lesion, usually has glands invoment
Cryotherapy can destroy lesion in 5 mm thickness.
HSIL Better to perform Excision.

Contraindication
Pregnant Woman
Cervix Cancer (Not Pre-cancer lesion
anymore)
Active infection in vagina, cervix, or pelvix.

Technics
Preparation
Avoid pregnant woman
Clear from menstruation
Perform Gynecologic Examination and also
Colposcopic
Check N2O or CO2 tank, with pressure 20
psi.
Connected tank to cryogun, and probe.

Technics
Prepare patient in lithotomy potitions
Inserting vagina speculum
Check all lesion area in cervix
Inserting Cryoprobe to vagina and place in
Transformation Zone area
Freezing for 3 4 minutes after ice crystal
performed in 4 mm arround abnormal
lesion.

Technics

Defrosting probe and take out probe from

vagina.

Apply antibiotics cream to portio.

 Reepitelization has done in 6 weeks in 47 %

patient and 3 months for all patients.
First day : Hiperemia
Second day : bullae or vesikel, and also
oedema
After that the tissue will recover in granulation
and reepiteization process.

3 months after

Side Effects and

Complications
Vaginal discharge that can be done in 1
month
Spotting vaginal bledding in 1-2 weeks
Pelvic Imflamatory Disease < 1%, Necrotic
plug tissue in < 3% patients.

Effectiveness
Cure Rates (%)
Berget, 91
Olatunbosun, 92
Tangtrakul, 83

CIN 1
90.9
83.3
88.9

CIN 2
90.9
96.9
85.7

CIN 3
86.4
80.8
78.5

Double Freeze
cytology + histologic + colposcopy confirmation @ 1 year

Conclusion
Effective
Cheap
Easy to perform, and
Save

Loop Electrosurgical Excision Procedure (LEEP)

Loop Electrosurgical Excision

Procedure (LEEP)
A LEEP excisional biopsy and a LEEP conization
(utilizing a loop or triangle electrode to excise a
cervical cone) are procedures that can be performed
in an outpatient setting under local anesthesia.
These procedures can be both diagnostic and
therapeutic, and replace traditional follow-up
evaluations and treatments such as cold knife
conization and hysterectomy.

Loop Electrosurgical Excision

Procedure (LEEP)
In some settings, LEEP is used as a see and treat
method after a visual test such as VIA or colposcopy
(if available) has identified a potential precancerous
lesion, since the goal in most clients is to remove the
lesion and the total transformation zone.
The term Large Loop Excision of the Transformation
Zone (LLETZ) is used interchangeably with LEEP in
many textbooks.

Equipment Used to Perform

LEEP/LLETZ/LEEP Cone

Equipment Used to Perform

LEEP/LLETZ/LEEP Cone

Foot pedal
with
connectors
to ESU

Eligibility for LEEP

The eligibility is the same as the eligibility for cryotherapy but in

addition larger lesions (not suitable for cryotherapy) or lesions with
extension in the vagina or into the endocervix canbe treated with LEEP
depending on national protocols and practices.
The most common reasons for referral would be: a lesion too large to
fit under the probe, a lesion with endocervical extension, or lesions
where there may be uncertainty of possible early invasive disease.

Eligibility for LEEP

A LEEP conization can be diagnostic and therapeutic at the

same time and be an alternative to cold knife conization or
hysterectomy.
In case of failure of cryotherapy after VIA and the persistence
of an acetowhite lesion, LEEP would be the preferred treatment
option when available.

Contraindications for LEEP

LEEP should not be performed in :

1.
2.
3.
4.

the presence of pelvic inflammatory disease (PID),

acute cervicitis, or
symptomatic vaginitis.
Patient should have no medical condition for which a local
anesthetic is contraindicated.

Power settings for the different types

of electrodes

Excision of an ectocervical lesion

with one pass

Excision of an ectocervical lesion

with multiple passes

Excision of an ectocervical lesion

with multiple passes

Step-by-Step LEEP
Prior to placing patient on table for procedure:
1. Determine the womans eligibility for LEEP.
2. Take general medical history; determine if allergies are present
and of there are any contraindications to the procedure.
3. If there is an evidence of infection indicated by client history,
examine the client. If an infection is confirmed, delay LEEP and
treat the infection.
4. Explain the procedure, counsel the woman, and obtain consent
to perform LEEP.
5. Prepare the LEEP tray (contents shown in Picture 5).
6. Connect the ESU and smoke evacuator to the electrical outlet
and verify functioning electricity.
7. Connect tubing to the smoke evacuator, and the loop electrode
cord to the ESU.

Step-by-Step LEEP
Prior to activating electrode and conducting the excision:
1. Have the woman empty her bladder and undress.
2. Prepare the table with drapes and place the light source in
proximity. Have a stool close by for the operator to sit on.
3. Place the woman on the table in a modified dorso-lithotomy
position with her feet comfortable in stirrups, buttocks at edge
of table, and a comfortable position for her theback and head.
4. Place a reusable patient return electrode under her buttock or
on her thigh and connect to the electrosurgical unit.
5. Wash hands with soap and water and dry with clean dry towel
or air dry.
6. Put high-level disinfected surgical gloves on both hands.
7. Connect the smoke evacuator tubing to the insulated
speculum.
8. Insert the speculum and centralize the cervix. The cervix
should be perpendicular to the path of the loop electrode.
9. Determine if a lateral vaginal wall retractor needs to be placed

Step-by-Step LEEP
Prior to activating electrode and conducting the excision:
10. Remove excess secretions from the cervix with saline.
11. Apply 5% acetic acid first to delineate the lesion, followed by
Lugols Solution to outline the precancerous lesion and
transformation zone.
12. Determine which triangle or loop electrode will be used to
excise the lesion and transformation zone. If possible, one
pass and one excision should be planned, but that is not
always possible.
13. Inject 34 cc of a local anesthetic in a ring pattern
intracervically.
14. Wait 1 minute.

Step-by-Step LEEP
To perform the electrosurgical excision:
1. Set the ESU to the appropriate blended power setting for
the electrode chosen
2. Plan the cut with the electrode (NOT activated), and
simulate the entry point, the pathway, and the exit point. The
goal is to remove the lesion and transformation zone with a
35 mm margin.
3. Turn on the smoke evacuator and check if electrode can be
activated by turning on the switch. If both are functional,
proceed with excision.

Step-by-Step LEEP
4. Do the excision under clear visualization.
a. Triangle electrode: Place the tip of the triangle loop in the endocervix at 12
oclock. Activate the electrode and advance the electrode to its base at 12
oclock and then proceed in one slow but continuous movement with a rotation of
360 degrees until a cone-shaped specimen is excised. Do not push the
electrode, guide the electrode. Once the specimen is excised, deactivate the
electrode.
b. Curvilinear electrode (loop): Enter electrode at determined entry point and make a
pass from south to north or west to east to excise lesion in one slow and
continuous movement. Insert to a minimum of 5 mm or a maximum of 10 mm at
beginning of the pass. Once the specimen is excised, deactivate electrode.
c. Sometimes there are lesions which require two or more passes to excise the
whole lesion, or a lesion may require an additional top hat excision of the
endocervix.

Loop electrode being positioned over area to be

excised (top) and initial insertion of probe
into cervical tissue (bottom)

Loop electrode being passed through cervical

stroma under the transformation zone (top)
resulting in an excisional biopsy (bottom)

Rectangular probe being used to excise tissue from

higher in the endocervical canal

Step-by-Step LEEP
5. Pick up excised specimen(s) with ring forceps and place them in
formaline solution, if the specimen needs to be sent for histology.
6. Change settings on the electrosurgical unit to coagulation and choose
the ball electrode. For smaller lesions choose the 3 mm ball electrode
and for larger lesions choose the 5 mm ball electrode (see Table 1 for
power settings for electrodes).
7. Coagulate and fulgurate the wound bed until hemostasis is achieved.
Fulgurate margins of the wound crater. Use swabs to remove blood
clots. If carbonization of the ball electrode occurs, remove carbon from
the ball.
8. Apply Monsels Paste to the cervix with a swab. This solution can be
applied generously to prevent later oozing. Pressure does not need to
be applied. The swab should be removed immediately after application
of the Monsels Paste.

Step-by-Step LEEP
10. Help the woman to a sitting position, determine if she is stable
enough to step off the table, provide her with a pad, and ask her to
dress.
11. Counsel the woman on anticipated post-procedure effects (e.g.,
spotting, excessive discharge for one month, and mild cramping for 2
3 days). You should also counsel her on when to follow up, and on
abstaining from sexual intercourse. Provide her with the prepared
package of after-care products (including sanitary pads, post-LEEP
information sheet, and a condom supply).
12. Place all reusable instruments in appropriate containers for cleaning,
disinfection, and sterilization.
13. Place contaminated non-reusable materials and accessories in
identified biohazard trash containers.
14. Clean the table, lights, and any contaminated objects in accordance

Potential adverse effects of LEEP

1. The potential short-term adverse effects of LEEP are:

a. Abdominal cramps in about 5% of women after the procedure;
b. Severe bleeding during procedure in less than 1% of women;
c. Delayed bleeding in 46 days in less than 1% of women after
the procedure which is usually controlled by fulguration, silver
nitrate application or Monsels Paste.
2. The potential long-term effects of LEEP are as follows:
a. Less than 1% of women experience cervical stenosis.
b. 2% of women experience inadequate visualization of the
squamo columnar junction.
c. There is a small increase of risk for preterm birth.
Please note: Women should be informed that there is no known
effect on fertility.

Effectiveness of LEEP and follow-up

management
LEEP has been found to be extremely effective. 9095 % of
women will have no precancerous lesion at the 12 months followup.
a.If at 12 months lesions are seen that are new or persistent, treat
with cryotherapy, redo LEEP or cold knife conization on an
individualized basis.
b. If the lesion is still persistent at follow-up, repeat LEEP with
cone-shaped excision.
c. In settings where colposcopy and histology is available,
diagnostic procedure may be chosen to precede a cone procedure
or on occasion a hysterectomy.
d. If no lesion is seen at the follow-up visit by VIA, recommend